What is leukoderma (vitiligo) and how is it treated in individuals of all ages and ethnicities?

What is Leukoderma (Vitiligo)

Leukoderma, also known as vitiligo, is an acquired autoimmune skin disorder characterized by the loss of melanocyte pigment cells from the epidermis, resulting in well-defined white patches that are often symmetrically distributed. 1, 2

Disease Characteristics

• Vitiligo affects approximately 0.5-1% of the population worldwide, occurring equally in males and females, with average onset around age 20 years 2, 3, 4
• The condition results from autoimmune destruction of melanocytes, with autoreactive cytotoxic CD8+ T cells targeting pigment-producing cells through IFN-γ mediated pathways 5
• Common sites include fingers, wrists, axillae, groins, and body orifices such as mouth, eyes, and genitalia 2
• The depigmented skin lacks melanin protection, making it more sensitive to sunburn 3, 4

Classification

Vitiligo is classified into two main types: non-segmental (vitiligo vulgaris) and segmental vitiligo, distinguished by distribution pattern and symmetry. 2

• Non-segmental vitiligo presents as symmetrical depigmented patches that typically increase in size over time, representing the most common presentation 2
• Segmental vitiligo shows unilateral, asymmetrical depigmentation confined to one body segment, which may follow dermatome distribution 2
• Disease activity classification is clinically more relevant than traditional staging, with stable disease defined as no new lesions, no Koebner phenomenon, and no extension for at least 12 months 2

Diagnosis

• Classical symmetrical presentations can be diagnosed confidently in primary care, while atypical presentations require dermatology referral 1, 2
• Wood's light examination helps delineate pigment loss, particularly useful in lighter skin types (I and II) 1, 2
• Check thyroid function tests in all adult patients with vitiligo, as autoimmune thyroid disease occurs in approximately 34% of cases 1, 2, 6

Treatment Approach

Localized Disease (First-Line)

For localized vitiligo, potent topical corticosteroids or calcineurin inhibitors are first-line treatments. 2, 6

• Potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) applied twice daily achieve 15-25% repigmentation in approximately 43% of patients 6

  • Critical limitation: Use for maximum 2 months only due to risk of skin atrophy 2, 6

• Calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) provide comparable efficacy with superior safety profile, particularly for facial involvement 2, 6

  • These can be used long-term without atrophy risk 2

Widespread Disease

For widespread vitiligo, narrowband UVB phototherapy is preferred over PUVA due to greater efficacy and safety. 2, 6

• Maximum of 200 treatments for skin types I-III 6
• Narrowband UVB (311 nm) has become the standard phototherapy approach 3, 4

Surgical Treatment (Stable Disease Only)

Surgical interventions are reserved exclusively for stable disease with no progression for 12 months and should only be used for cosmetically sensitive sites. 2

• Segmental vitiligo achieves best surgical results with >75% repigmentation in 71% of cases 2
• Techniques include suction blister transfer, mini-grafting (1.0-1.2 mm punch grafts), and cultured epidermal autografts 2, 7
• Surgical interventions are absolutely contraindicated in active disease with progression within 12 months 2

Oral Therapies (Limited Role)

The British Association of Dermatologists explicitly recommends against oral dexamethasone for vitiligo due to unacceptable side-effects. 6, 8

• Low-dose oral prednisolone may be considered only for actively spreading disease as a maximum 4-month tapered course after exhausting topical options and phototherapy 8
• Ginkgo biloba extract may be considered as adjunctive therapy with minimal side effects, particularly for acrofacial vitiligo 8

Monitoring and Psychological Support

• Take serial photographs every 2-3 months to objectively document disease progression or response 6, 8
• Assess quality of life impact at initial consultation, as vitiligo can be psychologically devastating, causing social isolation, depression, and difficulties in relationships 1, 2
• Screen for development of other autoimmune conditions during long-term follow-up 2, 6

Critical Pitfalls to Avoid

• Never use potent topical steroids beyond 2 months due to skin atrophy risk 2, 6
• Never perform surgical interventions on active disease - wait for 12 months of stability 2
• Never fail to check thyroid function in vitiligo patients given the 34% prevalence of autoimmune thyroid disease 1, 2, 6
• Never overlook the psychological impact - this is often more significant than the physical disease itself 1, 2